Healthcare Provider Details

I. General information

NPI: 1568656080
Provider Name (Legal Business Name): MAXIMILIAN MAGALA BAUTISTA D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2007
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2664 BERRYESSA RD SUITE 201
SAN JOSE CA
95132-2925
US

IV. Provider business mailing address

2664 BERRYESSA RD SUITE 201
SAN JOSE CA
95132-2925
US

V. Phone/Fax

Practice location:
  • Phone: 408-272-2330
  • Fax: 408-272-2665
Mailing address:
  • Phone: 408-272-2330
  • Fax: 408-272-2665

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number45822
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: